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Letting Alcoholics Drink

A monumentally important research study allowed homeless men in shelters to drink. Over a year, these alcoholic men drank less and spent far less time in detox, jail, and hospitals, which in turn reduced per capita costs significantly. This study challenges America's AA-abstinence-only orthodoxy, including the mantra that alcoholics will end up in jail, a hospital, or dead if they don't stop drinking.

Shelters are notoriously dry places that refuse intoxicated or drinking residents. A group of University of Washington public health researchers published in the April 1 issue of the American Medical Association's flagship journal (JAMA) a study finding that allowing alcoholics to drink and still to enter public homeless shelters produced indisputable benefits to society and for the alcoholics themselves.

In practice, banning drinking in shelters sentences alcoholics to the streets. The study compared 95 chronically alcoholic men who were allowed to drink in shelters, on the one hand, with another group of 39 who were wait-listed. The study was thus "quasi-experimental," comparing randomly selected groups in terms of outcomes based on a single intervening factor - being allowed to continue drinking and yet still having housing.

The results were unquestionable. Leaving drinking alcoholics on the street is a remarkably expensive proposition: due to their repeated stints in jails, hospitals, and detox, the alcoholics admitted to "wet housing" had spent $8 million in public funds the year before the study. For the year of the study, their costs were approximately two thirds less (counting housing costs), going from a median of $4,000 monthly to $1,500 relative to the control group and their own prior costs.

Most exciting of all, the costs continue to decline the longer they stay in the wet housing, down to a thousand dollars per resident at the end of the year. And, despite the permission to drink, these long-term alcoholics reduced their consumption, from an average of 16 drinks daily at the start to 14 drinks at six months to 10 drinks daily by year's end.

For decades, American researchers have fought to provide controlled-drinking therapy, or to count reduced drinking as a beneficial outcome. This has not been a popular position to take in this country - a battle that has spilled onto the pages of Psychology Today. (Three American psychologists in this movement have been Alan Marlatt, one of the authors of the current study, William Miller, developer of motivational interviewing, and me.)

But the JAMA study did not concern therapy. Shelters often insist that the men enter AA, but this program required no treatment. Simply allowing the men the right to be housed (the project is called "Housing First") had the impact of improving their lives and social costs at the same time. This is called harm reduction.

Of course, AA proponents can boast how quitting drinking has sanctified them. They can then claim these men's lives would be immeasurably better if they only got sober. But this is not the reality of "street" alcoholics. Discarding the bromides of American alcoholism treatment improved these men's lives decisively, and promises to continue the improvement going forward.

There was no no-drinking-in-residence control group because chronic street inebriates refuse to enter shelters where they can't drink - that's why "Housing First" was created! This is reflected in this sentence in the post: "In practice, banning drinking in shelters sentences alcoholics to the streets."

Hence, the so-called quasi-experimental design where the control group were non-admitted street alcoholics - (as well as using the pre-intervention behavior of the housed drinkers for a comparison). I'm not sure if you know Alan Marlatt's name (the psychologist behind the research design in this case), but he knows how to lay out experimental squares, as in his famous 2x2 design of drinking v. non-drinking alcoholics, expecting v. non-expecting alcohol.

I wrote Alan praising him for "going to the streets" at this point in his career to create a highly policy-relevant, impactful study publishable in JAMA, where it will reach ordinary physicians with its life-saving information, despite being highly controversial in terms of America's abstinence fixation (which you seem to share), despite the need to violate ideal laboratory experimental design, which in this case was totally irrelevant.

What an interesting post. A lot of food for thought. It made me think of de-institutionalization. Due to inhumane treatment the mentally ill were released from institutions and put on the streets. The notion of protecting people from horrific "treatments" and allowing them the choice to refuse medication or therapy is very noble but we seem to have fully lost track of the choice part. There is no doubt that the vast majority of homeless people have both a psychiatric problem and substance problem, one precipitated by the other at times but usually comorbid. So we turn to our ill and say, "We wont force you to get help but we wont even offer basic help like housing until you help yourself." It seems to go against the whole touted disease model. If drinking is really a disease than why are we blaming it's vicitims and labeling them unworthy of a place to sleep? Very hypocritical to promote an all or nothing disease model and yet hold people in such low esteem for drinking that they are sentenced to the streets. Mental instututions were taken to task, now it's time to take our modern institution to task as well becasue it's pretty darn crazy! I am in full support of "housing first." Help before you judge. What a beautiful lost concept.

You make a point that I have felt passionate about for years... allowing the mentally-ill to "choose" to not get well. It's a multi-faceted argument. The rights of a patient vs. the rights of society ( including hopefully those who love the patient). I see both sides of it and advocate for both. At the end of the day, we benefit from having a professional intervene with reasonable unbiased judgment to hold a patient "against his will," if it is deemed necessary. The problem with this is that said "professional" has an ENORMOUS responsibility to do the "right thing" for the mentally-ill, as well as his society. If a state has the right to force me to wear a seatbelt against my will, then perhaps that same state has a right to "treat" me for mental illness against my will? Again, I feel passionately on both sides of this argument, and ideally advocate for a fulfilling life and reconnection with family and friends, rather than the despair of a "man on the street."

Dear Unbiased,
You have a heart that is full of compassion. But let me remind you, we cannot choose the fence, for if you do not choose, you have allowed others to choose for you. Regarding the subject at hand, do you not believe that a person's rights end at the place where those rights trample on the rights of others. Mental illness must be addressed for reasons including, but not limited to, the rights of the mentally ill. It is a difficult balancing act. The seat belt law attempts to save lives in society so that the society does not loose its precious human resources(amoung other reasons). Society is responsible for the lives of its members. In the case of mental illness (or drug addiction), the lives of the mentally ill AS WELL AS the lives of the innocent who are affected, are to be considered here. It appears that what this article/study shows is that there is evidence suggesting that when we take both society and the individual interests and rights in mind, we are capable of coming up with inventive and effective ways of humane treatment.
I applaud this study and hope more studies like this follow.

Nice article to read.There is no doubt that the vast majority of homeless people have both a psychiatric problem and substance problem, one precipitated by the other at times but usually co morbid. So we turn to our ill and say, "We wont force you to get help but we wont even offer basic help like housing until you help yourself."

I am pleased that a recent case study exists on this. I see a need to "connect the dots" that exist throughout civil services. I have seen a common thread of alcoholic homeless men to originate as the husband who abused the bottle, then abused his wife, then was escorted to county jail via deputy sheriff. Second offences sometimes lead to state prison rather than county jail. When release occurs, no one in the family will house him, so he quite literally walks out of the state facility with resentment, so he walks to a corner store and buys a bottle of $1.75 liquor in a capital city where he knows no one. A homeless man is born from an alcoholic who was born many years before. I'm a firm believer that allowing an alcoholic or mentally-ill person to sign himself out of an institution ( jail, emer. room, hospital, etc.) without a plan of where he's going, should not be allowed. We should "connect the dots" by requiring discharge administrators to have a plan of "where is this chronic alcoholic felon going when he leaves here?" If his answer is " I'll be alright," well... he will be picked up by an officer, medic, or coroner soon, and possibly harm others in an alcoholic stupor on the streets. A shelter for him to drink in moderation until detox is an option , is a link in a chain toward recovery. So many tensions exist toward helping "street addicts," similar to the tensions that exist in allowing citizenship for "illegal immigrants." In both cases, we save "tax-payer money" and better all involved, including communities, by tossing aside our disdain for "rewarding bad behavior" in lieu of common sense solutions to real problems. Anyone know of any other related case studies?